System and method for selecting healthcare management

ABSTRACT

The present invention is directed to a system and method which allows a prospective insured to make an informed decision on healthcare insurance or a specific health care management decision by using a current medical profile to assist in their selection. Based on past medical care, as obtained from payor data, a number of different plans, each having different providers, different deductibles, different maximums, different reimbursement policies, etc., a person can make an informed decision. When a family has different payors for different family members, a proper blend of payors can be more easily selected since the payors (or a single payor) has a medical profile of each family member and also has information on providers in the network, prescription policies, deductibles, maximums, etc.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is related to concurrently filed, co-pending,and commonly assigned U.S. patent application Ser. No. 11/023,199,entitled “HEALTHCARE MANAGEMENT SYSTEM USING PATIENT PROFILE DATA,” thedisclosure of which is hereby incorporated herein by reference.

TECHNICAL FIELD

This invention is related to medical systems and more particularly tosystems and methods for providing assistance in making healthcaredecisions, and even more particularly to a system and method forassisting in the selection of a healthcare manager

BACKGROUND OF THE INVENTION

A problem occurs when a person is attempting to make a health caredecision, such as, for example selecting a medical insurance (or evenlife insurance) plan suitable for that person or for that person'sfamily. Different plans have different deductibles for differentprocedures. Different plans also have different healthcare providerscharacterized as “in-network” or “out of network” providers. Since the“proper,” i.e. lowest cost plan that meets the individual's and/orfamily's needs will ultimately depend upon what medical services thatperson (or family) will require over the life of the plan and since thatinformation is, by definition, not known at the time of plan selection,the solution is usually a “best estimate” guess. With something ascrucial to a person's physical and financial health as medicalinsurance, the existing system for selection of a proper plan leaves agreat deal to be desired.

One example of the problem arises when a family tried to decide whichmedical management plan to sign up for at work. Assume both the husbandand the wife each have several options. Also assume that the husband iscurrently seeing Doctor A for a specific illness. Also assume that thewife is of child-bearing years but they already have two children. Inour example, the husband's plan is less expensive than the wife's planand includes Doctor A. If this family were to accept the wife's planthey would pay more per month and if the husband were to continue usingDoctor A he would not be reimbursed the full amount because Dr. A is noton the “in-network” list of the wife's plan. Based on the availablefacts, it appears that the husband's plan should be selected.

However, this analysis did not take into account the reimbursement formedications for each plan, nor did it take into account the medicalcosts for the two children. Also not taken into account is thelikelihood of a long-term illness to a family member where medicationcosts, hospital reimbursements, perhaps home-care costs and certainlymaximum limits could drastically affect the overall cost of medicalassistance.

Also not taken into account is the fact that different types ofprocedures require different expertise. Thus, a particular group ofmedical providers may yield statistically better results than anothergroup for treatment of a specific ailment. Thus, deciding upon ahealthcare plan, or even upon a course of healthcare treatment, requiresmore information than is currently available to a potential healthcarepurchaser.

BRIEF SUMMARY OF THE INVENTION

The present invention is directed to a system and method which allows aprospective insured to make an informed decision on healthcare insuranceby using a current medical profile to assist in the selection of futuremedical insurance. Based on past medical care, as obtained from payordata, a number of different plans, each having different providers,different deductibles, different maximums, different reimbursementpolicies, etc., a person can make an informed decision. When a familyhas different payors for different family members, a proper blend ofpayors can be more easily selected since the payors (or a single payor)has a medical profile of each family member and also has information onproviders in the network, prescription policies, deductibles, maximums,etc.

In one embodiment there is provided a system and method for combiningactual past medical payor information, as obtained from a profile of apatient's (or a patient's family) medical history, so as to help selectthe proper plan going forward. In an embodiment, the system willextrapolate from actual data to form an anticipated going-forwardmedical projection for the family. In a further embodiment, the systemand method accepts data from the family concerning their own plans forthe future so as to refine the medical projections, thereby furtherreducing the guess factor in the selection of a medical plan.

In another embodiment, options to a medical course of action areprovided to a patient based upon prior experience the patient'shealthcare plan has with providers in the patient's coverage area. Usingsuch a system and method a particular group of medical care providersmay be selected for a particular procedure based on those provider'sstatistical data. In addition, a particular medical facility may bedetermined to be a better match for the patient, given the entiremedical history of the patient and the past track record of thehealthcare facility. Thus, in some situations it maybe beneficial forthe patient to go outside the network for a particular treatment.

The foregoing has outlined rather broadly the features and technicaladvantages of the present invention in order that the detaileddescription of the invention that follows may be better understood.Additional features and advantages of the invention will be describedhereinafter which form the subject of the claims of the invention. Itshould be appreciated that the conception and specific embodimentdisclosed may be readily utilized as a basis for modifying or designingother structures for carrying out the same purposes of the presentinvention. It should also be realized that such equivalent constructionsdo not depart from the invention as set forth in the appended claims.The novel features which are believed to be characteristic of theinvention, both as to its organization and method of operation, togetherwith further objects and advantages will be better understood from thefollowing description when considered in connection with theaccompanying figures. It is to be expressly understood, however, thateach of the figures is provided for the purpose of illustration anddescription only and is not intended as a definition of the limits ofthe present invention.

BRIEF DESCRIPTION OF THE DRAWINGS

For a more complete understanding of the present invention, reference isnow made to the following descriptions taken in conjunction with theaccompanying drawing, in which:

FIG. 1 is one embodiment of a system and method for consolidatingmedical information from a myriad of healthcare providers;

FIG. 2 is one embodiment of a method for obtaining and profiling medicalinformation; and

FIG. 3 is one embodiment of a method for assisting in the selection of ahealthcare management plan.

DETAILED DESCRIPTION OF THE INVENTION

The forms which are filed (usually electronically) by healthcareproviders for reimbursement from payors contain clinical data pertainingto the patient. In addition, health care plans use pharmacy benefitmanagement companies (PBMs) to evaluate and pay pharmacy claims. Thisprocess of verification generates pharmacy data which then complimentthe treatment and diagnostic data obtained from doctors. In addition,when a physician orders a laboratory test, the test costs are billed foreither by the ordering physician or by the providing physician, such asby a radiologist. The claim for payment also goes to the payor. In somesituations the actual test results will go the payor, or can be obtainedby the payor in an electronic format.

The system and method described herein takes advantage of the fact thatall of this data funnels through a common point and can be used toprovide a comprehensive holographic view of a patient's health. Thus, inthe disclosed system and method, the health plan acts as the aggregatorof information pertaining to its members and that aggregated informationis used to create a meaningful representation of the medical profile ofthe member.

Turning now to FIG. 1, system 10 shows one embodiment of a system andmethod for consolidating medical information from diverse sources, suchas Service Provider 11, to give a consolidated profile of a patient.Service provider 11 represents service providers which could encompasstest lab 101, pharmacies 102, hospitals 103, and physicians 104 claimsfrom any provider are submitted to a patient's insurer 12. Others, suchas the user, user's family, or even unrelated systems such as, forexample, a credit card profile system, shown as 121, can also submitclaims to insurer 12. At least a portion of the information coming fromthese various diverse sources is stored in database 13. While it iscontemplated that the raw data be stored in database 13 it could be thatonly abstracted data (such as above or below limit data) is so stored.Also note that database 13 could accept data from other insurers 19which could occur, for example, if a patient were to have multipleinsurers (husband and wife; private and government, etc).

Assuming patient 16 used provider 15 as a primary provider but also usedother providers 17 (cardiologist, diabetic specialist,obstetrician/gynecologist), it could be appropriate for any one or moreof these providers to set “rules” for the patient. These rules couldpertain to filling and refilling a prescription, taking and sendingcertain monitored readings (sugar levels, air flow, etc.), limits oncertain readings, etc. These rules are stored in rules engine 18 on apatient-by-patient basis and when a rule has been attained (i.e., acertain monitored fact is outside a limit), then monitor application 14sends a message, (e-mails, telephone, fax, etc) to provider 15 (andpossibly also to one or more other parties, including the patient);

Claims are submitted from various service providers, as well as thepatient, and these claims may be formatted differently based on thereason for the data exchange. To handle such a situation, properinterfacing between systems is required and this is handled by adaptors,such as adapters 130.

One example of how the system and method could work is where physician Ahas prescribed a particular medication for a patient and physician B,possibly because that patient failed to inform physician B of themedication he/she is taking, prescribed another medication that might bedangerous when mixed with the first medication or possibly negates theeffects of the first medication. In such a situation, the system wouldgenerate an alert to the patient and, if desired, to both physicians Aand B. The reason the alert can be delivered is because of the compositeview of a patient's medical history as obtained from payment records.Since the system is based upon data coming to a payor for reimbursement,over-the-counter medicines or medicines that are not paid for by theprovider will only get into the system if the patient (or someone actingfor the patient) sends in the data.

Another example would be if a patient has asthma and is asked to measurehis/her peak air flow daily and to call the physician if the readings gobelow a certain level. Frequently patients don't follow through with theinstructions or are worried about calling (“bothering”) the physician.Using this system a member could go online to record his/her peak flowevery day. This on-line data is then sent to the system. A rule is setup in the system that says: if air flow falls below a certain level, orif there is a significant downward trend, issue an Alert Thus, even ifthe patient is not at the critical stage, alerts are sent and troublecan be averted. The physician cannot take phone calls from patientsevery day and calculate changes to air flow, but the provider could setthe system to accept a patient's input and to call (alerts) when certainlimits are met. In addition, patients can input symptoms, such ascoughing, vomiting, chest pain, headaches, temperature, blood pressure,etc., and this data can be used to trigger an alert based either on ageneral group rule, or on parameters set individually for that patient.

Compliance by a patient is another major concern. For example, theprovider asks a patient to take a medication, monitor peak air flow tolungs, check blood sugar, see a specialist, etc. In reality, theprovider does not know whether the patient has complied or not. When thepatient ends up in the emergency room because of failure to followdirections it is often too late for help. However, using the system andmethod described herein, the provider will be notified if certain valuesdecrease or change or hit a certain level. Alerts will be generated ifthe values are missing, i.e., not put in for two or three consecutivedays, etc., Also, missing data could be that a prescription has not beenfilled (or refilled on time), thereby initiating an alert.

These are all examples of the power obtained when the medical history ofa patient can be generated and continually monitored based upon anabstraction of data meant for another purpose, namely paymentinformation.

FIG. 2 shows one embodiment of system 20 where process 201 receivesreimbursement information (a payment claim) from any one of a number ofmedical providers. This information contains within it enoughinformation so that the third party payor can process the payment todetermine how much will be reimbursed. This reimbursement can be sentdirectly to the provider or sometimes it is sent to the patient. Eachsuch claim must contain with it enough information so that the payor canproperly determine the procedure that was performed, and whether thepatient is eligible for reimbursement and what the limits are. Often theprovider sends minimal information that certain tests have beenperformed and does not send the actual test results. However, in somesituations, the actual test scores are sent with the payment claiminformation. Pharmacies send in the prescription and sometimes also thediagnosis along with their claim information. In FIG. 1 this informationis shown coming from service providers 11 and goes directly to insurer12 but the data could pass through adapters 120 designed such that thedata from each provider is converted so that pertinent data can beremoved, as desired, for storage in patient profile storage 13.

In addition, process 201 will process data from a patient, such as frompatient 105 (FIG. 1). This data could be test results that have beenself-administered, such as blood sugar levels, peak flow levels, bloodpressure, temperature, or any other measurable physiological parameterthat is necessary for a medical diagnosis. In addition a patient caninput symptomatic information, such as chest pain, coughing, vomiting,or any other type of occurrence, such as blurry vision, or abdominalpain, all of which will be received by process 201 and processed tobecome part of the patient profile information stored in storage 13.

Process 202, either before the information is stored in patient profile13 or thereafter, and with or without the help of adaptors 120, createsan abstract of the information to determine certain information. Forexample, process 202 could look at various pieces of information andconclude that a patient is a diabetic. This would be concluded, forexample, by looking at the medication the patient is taking, patienthospital visits, supplied lab test results, etc., and applying rulesunder control of rules engine 18 (FIG. 1) to conclude that this patientis in a group of diabetics. Other types of information could lead to anabstracting of a patient so that the patient is classified as a heartpatient, a pregnant patient, etc. Each of these categories could thenrequire the further abstracting of information to determine fromsymptoms provided by the patient when to send an alarm.

For example, if a patient is classified as having heart failure, thenupon receiving information from a patient that the patient is havingnight time cough, the system would, based upon process 204, determinethat this patient (or his/her health care provider) needs be alerted.

The system is established such that an administrator, who could be adoctor, could establish parameters that would apply to all of thepatients in the database. This information would apply to the wholepopulation of patients falling within the rules for the group. Withineach group each physician could establish specific parameters forhis/her specific patients.

Process 203, as discussed, stores the pertinent data either in patientprofile storage 13 or in other storage and based upon rules establishedby rules engine 18. Process 205 determines if an alert is necessary. Ifan alert should be sent, such an alert will be processed via process 206to determine what type of an alert, who the alert should go to, and how,and will also determine what type of data should be supplied. Process207 sends the alert to one or more providers, other third parties, or tothe patient, as desired. Process 220 sets rules for the rules engine ona per-patient basis while process 221 sets rules for groups of patients.Process 204 examines the data under control of the rules engine, or anyother comparison system.

Turning now to FIG. 3 there is shown method 30 whereby the person whodesires to begin the process of selecting a medical reimbursement plan,or to select life insurance or other situations where the amount ofmoney a person receives or pays is dependent upon a particular plan orpolicy or to determine a proper course of treatment, will get online viaprocess 300. Process 300 can include, for example, a computer connectedto the system via an Internet connection or it can be a personrequesting assistance by telephone. Process 300 can, for example, run ona processor at a central location having access to patient profile data,such as patient profile 13 of FIG. 1, or the processor can run local tothe patient based on downloaded (or accessed) data. The person seekingthe information herein will be called the user.

Process 301 obtains medical, and medical cost profiles for the user andfor any others having affinity to the user, such as the user's family orany other person that the user has responsibilities to pay the medicalbills for. Process 30 also then obtains the plan information via process302 for all of the plans that are available to the user, including thoseplans available to the user's spouse and perhaps even for plans that areavailable over-the-counter. Plan information can include, for example,medication formularies, benefits, funding mechanisms, limits,deductibles, in-network and out-of-network fees, prescription costs,co-pay charges, etc.

One option would be to use a questionnaire via process 303 to submitanswers from the user via process 304 pertaining to medical factorsknown only to the user. For example, these questions could deal withfuture (or current) pregnancies or elective surgery or could evensolicit symptomatic information (chest pain, etc.). The questions couldalso pertain to dental situations with respect to braces, and any othertype of information that would bear upon the ultimate cost of healthinsurance. These processes could compile a patient profile consisting ofmedical history, preferred providers, current medications, plannedmedical interventions, and other pertinent information for choosingamong a variety of health plan options, including the patient'sfinancial risk profile and preferences. Process 303 can be set up for aspecific anticipated procedure, such as, for example, a knee replacementprocedure. In such a situation, the system would seek information aboutthe patient's desires and concerns and, based on the patient's medicalhistory, ask other questions pertinent to the situation at that point intime.

Once this information is gathered, i.e. the patient's profile, the planinformation for several plans, answers to the questions via process 304,etc. then process 305, perhaps in conjunction with rules engine 18 ofFIG. 1, or using its own processor, can evaluate the options availableto the user. This evaluation is based upon the type of medication thepatient is taking, the different types of diagnoses and tests that havebeen performed over a course of time and by reviewing the medicalhistory of the user's family. A profile can then be established of theuser and the profile can be used to help the user determine which planwould be “best” for that user, or what the various options are “likely”to cost the user over a prescribed period of time. For a particularprocedure, the profile would provide options of providers and facilitiesfor selection by the patient. In some situations it might be better fora patient to use an out-of-network doctor and select a plan that paysfor a longer period of time or that handles a certain type of illnessbetter than others, even though on the surface such a selection iscounter-intuitive. In some cases, it could be beneficial for a plan tomake an exception for a certain user such that the user will actually bereimbursed at the in-network reimbursement rate even though the useruses an out-of-network provider. This could also be true on aprocedure-by-procedure basis. This follows since the system maydetermine that over the long run using an out-of-network providersand/or facilities will be the most inexpensive way for the plan tooperate for the given circumstances of the user's family or for a givenprocedure. Note that the displayed results may be by cost, by number ofavailable providers or by other criteria.

Using the system and method discussed herein, the system can take intoaccount the user's age, prior medical conditions, answers to questionsof lifestyle and a myriad of other situations. For example, how far auser drives impacts his/her likelihood of being involved in an accident.Does the user own a boat, an airplane, what are the travel plans of theperson, etc. Note that travel plans, as well as other lifestyleinformation are not medical information but they do have an impact onthe user's medical treatment and this should be factored into theprofile also. Note that this lifestyle information can come from theuser or from sources external to the user, such as, for example, areservation system or a credit card company. When all this informationis evaluated by process 305, comparisons are displayed for the user viaprocess 306. The information for such a display could be sent to theuser wirelessly or by wire line which could be wirelessly or wired tothe user. Thus the information could be displayed on the screen of acomputer (not shown) or communicated in an email or otherwise to theuser.

Although the present invention and its advantages have been described indetail, it should be understood that various changes, substitutions andalterations can be made herein without departing from the invention asdefined by the appended claims. Moreover, the scope of the presentapplication is not intended to be limited to the particular embodimentsof the process, machine, manufacture, composition of matter, means,methods and steps described in the specification. As one will readilyappreciate from the disclosure, processes, machines, manufacture,compositions of matter, means, methods, or steps, presently existing orlater to be developed that perform substantially the same function orachieve substantially the same result as the corresponding embodimentsdescribed herein may be utilized. Accordingly, the appended claims areintended to include within their scope such processes, machines,manufacture, compositions of matter, means, methods, or steps.

1. A method for assisting a user in selecting a medical reimbursementplan, said method comprising: abstracting, by a processor, medicalinformation coming to a first payor from medical providers before themedical information reaches the first payor, said abstracted informationpertaining to a particular patient and coming from diverse locations andfrom diverse disciplines, said abstracted information being datapertinent for subsequent comparison with medical reimbursement plans andbeing less than a totality of the information provided to said firstpayor pertaining to a particular patient; abstracting, by a processor,non-medical information coming from diverse locations and pertaining toa particular patient, wherein the abstracted non-medical information isselected from the group consisting of lifestyle information, travelinformation and information about future plans; wherein the abstractingincludes converting, by at least one adaptor prior to storing, themedical and non-medical information from one or more formats; storingthe converted abstracted medical and non-medical information over aperiod of time on a patient-by-patient basis; upon a request from auser, providing, by a processor, at least said stored information forcomparisons with medical reimbursement plans; displaying for the userthe comparisons with medical reimbursement plans; wherein the abstractedmedical information includes parameters for medical reimbursement plansavailable to the user through a spouse; further wherein abstractedmedical information coming to a payor of the spouse from medicalproviders pertaining to the spouse is obtained by a processor from thespouse's payor; and wherein the spouse's payor may or may not beidentical to the first payor.
 2. The method of claim 1 wherein saidabstracted medical and/or non-medical information is contained in amessage sent over the Internet.
 3. The method of claim 1 wherein saidabstracted medical and/or non-medical information provides a holisticview of said patient's medical condition.
 4. The method of claim 1wherein said abstracted medical and/or non medical information isestablished by at least one of the following: a health care provider, asystem administrator, a patient.
 5. The method of claim 1 furthercomprising: storing, in association with said abstracted medicalinformation, data arriving from individual patients, said datapertaining to testing results obtained by said patient.
 6. The method ofclaim 5 further comprising: storing, in association with said abstractedmedical information, data arriving from individual patients pertainingto future anticipated medical procedures.